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Biomedical subjects

R Lefering

Publications and source records attributed to R Lefering.

At least 37 records · Page 2Linked to original sources
PubMed1997

The impact of risk factors and pre-existing conditions on the mortality of burn patients and the precision of predictive admission-scoring systems.

Clinical experience has shown that concomitant diseases and risk factors have a significant influence on the patient's outcome. Since none of the currently available score systems consider the impact of concomitant diseases or risk factors on burn trauma mortality, the present study was planned to further evaluate the role of these factors. Four hundred and ninety-eight patients could be included in this retrospective analysis of prospectively collected data. Parameters documented were: sex, age, weight, height, laboratory data, TBSA, inhalation trauma (IHT), full thickness (3 degrees) burn and pre-existing conditions. Single-variable analysis (SVA), logistic regression and CART analysis were performed. The data confirm the role of age and TBSA as the strongest prognostic variables. Chronic alcohol abuse and smoking, IHT and pre-existing cardiac and neurologic conditions were also found to be significant. Borderline groups could be identified in the ABSI score (7-10), where the risk factors cause 'mortality-shifting'. It can be concluded that risk factors and pre-existing conditions have a significant impact on the prognosis of burn mortality and should be incorporated into further refinements of burn admission scores.

Adolescent↗
PubMed1997

Trauma score systems: Cologne Validation Study.

BACKGROUND: Most standard trauma score systems have been developed and validated in the United States. However, trauma differs between the United States and Germany. This prospective study tested the validity of eight current trauma scoring systems (Glasgow Coma Scale, Trauma Score, Revised Trauma Score, Injury Severity Score, TRISSTS, TRISSRTS, Prehospital Index, Polytraumaschluessel) in 612 patients in Cologne. METHODS: Between January 1, 1987, and December 31, 1987, 2,136 trauma related emergencies were seen by emergency physicians in the field. All trauma patients with a Trauma Score below 16 and a random sample of 10% of patients with a Trauma Score of 16 were included in the study (n = 625). Follow-up was successfully completed for 612 patients (97%). Their hospital outcome was correlated with their individual score result. RESULTS: All trauma score systems under study showed high accuracy rates. TRISSRTS and TRISSTS performed best with values of above 0.97 for the area under the receiver operating characteristics curve. CONCLUSION: We conclude that the standard trauma score systems are valid tools for patient classification and support TRISSRTS as the international reference score system for the assessment of injury severity. This validation will allow comparisons between different trauma care systems.

Adolescent↗
PubMed1997

[Current practice of incisional hernia reconstruction in Germany].

The results of a nationwide survey regarding the treatment of incisional hernias following open laparotomy revealed that the Mayo-duplication is the surgical technique preferred by the majority of surgeons. However, in exceptional situations alloplastic material is implanted by up to 50% of the surgeons asked. More than one forth of the departments performed more than 30 incisional hernia repairs per year. Even for complicated cases the surgeons' own estimation of their recurrence rates was 11.7%. Compared with the data (recurrence rate of the Mayo-duplication of 30%-50%) published in the literature there seems to be a quantitative and qualitative underestimation of the treatment of incisional hernias.

Germany↗
PubMed1997

[The trauma register of the 'Polytrauma' Committee of the German Society of Trauma Surgery as the basis for quality management in the management of severely injured patients].

The data of 1037 severely injured patients (mean ISS = 20) from 15 clinics were centrally and prospectively collected in the Trauma Registry of the German Society of Trauma Surgery and analyzed anonymously. Significant differences in respect to the treatment criteria (i.e., duration of basic diagnostics in severe trauma) and quality of outcome (TRISS method and Z statistic) were revealed for some clinics. The feedback of their data offers the associated clinics the possibility of identification of treatment phases that are worth being optimized.

Germany↗
PubMed1997

[Apache II score and prognosis of intensive care patients after trauma--results of a quality assurance study of 939 patients].

The APACHE II score is a well-known measure of illness severity and widely used for prognosis in the ICU. A total of 91 trauma patients were identified among 939 ICU admissions (18 months), and their actual mortality (11/91; 12.1%) clearly exceeds the prognosis due to APACHE II (7.1%). Trauma-specific scores (TRISS, ISS, and RTS) revealed much higher estimates: 13%-22% which confirms a systematic underestimation of risk of death score in trauma patients in the APACHE system.

APACHE↗
PubMed1997

[Effective costs of intensive care: TISS and TISS-28 for the evaluation of an intensive care unit].

In 1996, Miranda published the TISS-28, a simplified version of the well-known Therapeutic Intervention Scoring System (TISS) for the evaluation of intensive care. A prospective observational study in 939 patients compared both scores, and the TISS-28 was found to show less interobserver variation. A cost analysis based on 1995 data revealed a value of 68.70 DM per TISS-28 point, which can be used to calculate the average costs for groups of patients, e.g., 1410 DM for 1 day postoperative surveillance in the ICU.

Cost-Benefit Analysis↗
PubMed1996

Laparoscopic and conventional closure of perforated peptic ulcer. A comparison.

BACKGROUND: After the first successful laparoscopic closure of a perforated peptic ulcer in 1990, 18 patients with laparoscopic closure were compared to 16 patients with conventional surgery. METHODS: The endpoint adverse events (complications), pain intensity, operation time, fever, leucocytosis, and duration of hospital stay showed no clinically relevant differences. RESULTS: Consumption of analgesics was lower in the laparoscopic group. CONCLUSIONS: Laparoscopic closure of perforated peptic ulcer is technically feasible. The safety of the method and the benefit for the patient need proof by means of a randomized controlled trial.

Adult↗
PubMed1996

Laparoscopic cholecystectomy for acute cholecystitis: is it really safe?

The prospectively collected data from 530 cholecystectomies performed in a university clinic from October 1989 to March 1991 were analyzed after 1 to 3 years of follow-up. The aim of this study was to compare the results of laparoscopic cholecystectomy (LC) for acute cholecystitis with that for routine symptomatic gallbladders. The preoperative, intraoperative, and postoperative parameters of 424 routine (noninflamed) LCs and 54 LCs for acutely inflamed gallbladders were compared under the "intention to treat" principle. Operating time was longer in the inflamed group (median 97 minutes versus 75 minutes; p < 0.0001). Significantly more adhesions (20% versus 8%), more blood loss (48% versus 19%), a higher incidence of bile spillage (28% versus 12%), and lost stones (19% versus 8%) were encountered in patients with acute cholecystitis. Common bile duct (CBD) injuries were also more frequent in that group (5.5% versus 0.2%; p = 0.005). The rate of conversion to open surgery was higher than with routine LCs (13% versus 4%). There were two deaths in the routine LC group and none in the acutely inflamed group. There was no difference in postoperative pain intensity or postoperative fatigue according to visual analog scale measurements. Patients with acute cholecystitis stayed only 1 day longer (median 4 days versus 3 days) in hospital. The quality of life scores indicate return to almost normal values by the 14th postoperative day. Long-term follow-up (1-3 years) did not reveal any delayed clinical adverse effects. In summary, LC for inflamed gallbladders has a higher conversion rate than LC for routine symptomatic gallbladders. If successfully performed, it has definite benefit for the patient in terms of better postoperative recovery. The trade-off is that the risk of CBD injury is significantly higher.

Acute Disease↗
PubMed1996

Duration of antibiotic treatment in surgical infections of the abdomen. Minimal antibiotic therapy: technology assessment instead of clinical trials.

In modern medicine which already uses maximal resources, additional improvements involve huge extra efforts. With increasing complexity of diseases, specific treatments have only a limited influence on the "whole process". In complex clinical situations (including sepsis and SIRS) the available methodology to identify groups of patients who may benefit from a specific treatment are weak. This is why prospective randomised "megatrials" may be needed to detect small differences in outcome. We suggest that careful prospective assessment of cohorts of well stratified patients, subjected to a specific and standardised treatment, may replace prospective controlled trials.

Anti-Bacterial Agents↗
PubMed1996

[Value of clinical scoring systems for evaluation of injury severity and as an instrument for quality management of severely injured patients].

Trauma Score Systems attempt to summarize the severity of injury in a single value. They provide a better classification of trauma patients and translate different severities of injury in a common language. They enable thereby comparisons between hospitals or trauma systems. Young doctors can control their clinical judgement with scoring systems and will gain experience. Scoring systems therefore increase safety and can help in decision making. As accuracy of scoring systems is never 100% individual decisions can never rely on scores only. Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score and TRISS are the most often used international scores for severely injured patients. Their sensitivity and specificity, validity, reliability and practicability have been studied and proved in many trials. The role of these scoring systems for quality management purposes in the treatment of severe trauma is actually studied with the Trauma Registry of the German Society for Trauma Surgery.

Cause of Death↗
PubMed1996

[The value of scores for therapy planning and therapy evaluation in individual intensive care patients--basic principles].

The utility of scoring systems in intensive care and emergency medicine has been approved for the classification of severity of diseases, quality assurance and cost performance of patient groups. There are obvious methodological pitfalls in using probabilities of mortality, which are estimates of risk of death, to predict specific outcomes for individual patients. They can only be used as a supplement to clinical decision making. Use of daily scoring systems can help in the description of the disease course of patients under treatment (trend analysis).

APACHE↗
PubMed1995

Probability of adverse events that have not yet occurred: a statistical reminder.

The probability of adverse and undesirable events during and after operations that have not yet occurred in a finite number of patients (n) can be estimated with Hanley's simple formula, which gives the upper limit of the 95% confidence interval of the probability of such an event: upper limit of 95% confidence interval = maximum risk = 3/n (for n > 30). Doctors and surgeons should keep this simple rule in mind when complication rates of zero are reported in the literature and when they have not (yet) experienced a disastrous complication in a procedure.

Confidence Intervals↗
PubMed1995

Long-term results after laparoscopic cholecystectomy.

As part of a continuing audit of patients undergoing laparoscopic cholecystectomy (which now numbers over 1500) 468 of the 508 patients (92.1 per cent) operated on between October 1989 and March 1991 were studied between 350 and 988 days after the operation (mean 19 months). A questionnaire was filled in by each patient before operation and at the late follow-up visit. Eight specific symptoms were sought-non-colicky pain, colic, abdominal distension, nausea, vomiting, loss of appetite, flatulence, and dietary restriction. The result of each operation was assessed by two surgeons and by the patient. In 453 patients (96.8 per cent) the symptoms had improved as a result of the operation, but 260 patients (55.6 per cent) had some abdominal symptoms. The result was assessed as excellent in 310 patients (66.2 per cent); 143 (30.5 per cent) still had abdominal complaints but they were willing to cope with those symptoms. In 15 patients (3.2 per cent) the result was unsatisfactory. Statistical analysis of 26 preoperative variables showed few significant differences between patients with excellent results and patients with persisting or new symptoms. The percentage of patients with biliary colic was reduced from 82.9 per cent before to 6.4 per cent after laparoscopic cholecystectomy (P < 0.05), and of those with flatulence from 62.6 per cent to 45.3 per cent (P < 0.05). Flatulence persisted in 147 (50.2 per cent) of the 293 patients who had complained of flatulence before the operation, and of the 175 patients who had not complained of flatulence before surgery, 65 (37.1 per cent) reported the symptom for the first time after the operation. It appears that 'flatulent dyspepsia' after cholecystectomy has many causes, one of which may be removal of the gallbladder. It is concluded that the long-term results of laparoscopic cholecystectomy in patients with symptomatic gallstone disease were excellent but the prognosis in individual patients was unpredictable.

Abdominal Pain↗
PubMed1995

Costs of Laparoscopic cholecystectomy. Analysis of potential savings.

Despite the growing acceptance of laparoscopic cholecystectomy the costs remain unclear. Therefore, a detailed cost analysis was performed to determine potential savings. As part of a continuing audit, data of 508 consecutive laparoscopic cholecystectomies have been prospectively collected. Pre-, intra-, and postoperative variables were assessed by standardized questionnaires. These data were used to estimate the average use of diagnostics, drug consumption, operation time, and hospital stay. In addition, costs for loss in income, "hotel services", diagnostic procedures, and for the operation itself were calculated in detail. The total costs for a standard laparoscopic cholecystectomy were 3,395 deutsche marks (DM). The costs for the operation itself represented 19%, "hotel services" and medical treatment except the operation such as nursing, visits, or diagnostic procedures represented 47%, and the loss of income another 33% of the total costs. Thus, most effective savings may be achieved by shortening the hospital stay and the time of inability to work. However, each additional 30 min of operating time costed 146 DM (4.88 DM/min) and an "ideal" operation performed within 40 mins and with a 3-day hospital stay would save 20% of the total and 31% of the hospital costs. An increase in the number of operations per year would not have a relevant impact on the cost. Disposable instruments would have increased the costs by 1,118 DM (33%). The costs for cleaning, packing, and disposal were only marginal. Reusable instruments were not related to any disadvantage either to the patients or to the staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

Steroid controversy in sepsis and septic shock: a meta-analysis.

OBJECTIVE: The use of corticosteroids in patients with sepsis or septic shock has been controversial for many decades. Clinical studies have reported beneficial, as well as negative results. We conducted a meta-analysis to assess the clinical evidence and to evaluate treatment effects in specific subgroups of patients. DESIGN: Meta-analysis. DATA SOURCES: A comprehensive search of the literature revealed 49 publications investigating the effect of corticosteroids in patients with sepsis and septic shock. STUDY SELECTION: Only ten of the 49 publications were prospective, randomized, controlled trials with an exact description of dosage and regimen. DATA EXTRACTION: Treatment effects on mortality were calculated as rate differences in each study (negative values favor steroids), and were combined with respect to the variability in each study. DATA SYNTHESIS: Only one study showed a significantly positive effect of steroid treatment. Overall, no positive effect was observed: -0.2% (95% confidence interval: -9.2, 8.8). There were no differences observed when comparing low- vs. high-dose or type of corticosteroid used. Comparing patients with proven Gram-positive or Gram-negative infection showed a slight but not significant difference. The Gram-negative group demonstrated better outcome (-5.6% vs. 1.8%). A quality rating of each trial showed a remarkable increase in quality over time. Adverse events (gastrointestinal bleeding, secondary infections, hyperglycemia) were not more frequent in patients treated with steroids compared with controls. CONCLUSIONS: No overall beneficial effect of corticosteroids in patients with septic shock was observed; however, there is some evidence for a positive effect in patients with Gram-negative septicemia.

Adrenal Cortex Hormones↗
PubMed1994

Technology assessment of endoscopic surgery.

Endoscopic surgery is considered a milestone in the evolution of surgical technique in nearly all fields of surgery. However, the inappropriate use of the new technology in medicine has also been heavily criticised. Systematic technology assessment of endoscopic surgical techniques is mandatory to prove the real benefits and complications, so defining the indications for their appropriate use. This article describes methods of technology assessment suitable for endoscopic techniques with emphasis on relevant endpoints for surgeons and patients. The general stages of a comprehensive technology assessment include: 1. feasibility (safety and technical performance) 2. efficacy (patient benefits in pioneering places) 3. effectiveness (patient benefits in average hospitals in the community as a whole) and 4. economic evaluation (cost-benefit analyses). We used the example of laparoscopic cholecystectomy to describe the methods of technology assessment. A cohort study on 500 patients revealed that laparoscopic cholecystectomy is as safe as the conventional standard open technique. The results on efficacy strongly support the hypothesis of more comfort and less trauma with the endoscopic technique. Major endpoints evaluated were postoperative pain, convalescence, fatigue and quality of life. Data on effectiveness and economics are still in a "premature" state and should be the subject of further analyses. It is concluded, that other disciplines such as neurosurgery should evaluate their endoscopic surgical techniques according to the rules of technology assessment outlined in this paper.

Cholecystectomy, Laparoscopic↗
PubMed1994

Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events.

It is postulated that laparoscopic cholecystectomy as "patient-friendly surgery" leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n = 382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. Pain was the most frequent symptom, both before and after the operation. The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day. In 106 patients (27.8%) the intensity of pain was higher than 50 VAS points. Analgesics were used by 282 patients (73.8%), opioids by 112 (29.3%). Pain was significantly higher in female than male patients (P < 0.05), but consumption of analgesics was similar in both groups. The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of > 50 VAS points (n = 138) had higher preoperative pain levels (P = 0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P = 0.003-0.031). However, predictive values of these variables were too small to be of clinical benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Pain↗